Propofol sedation using Diprifusor target-controlled infusion in adult intensive care unit patients.

This multicentre, non-comparative study investigated the range of target blood propofol concentrations required to sedate 122 adult intensive care patients when propofol was administered using Diprifusor target-controlled infusion systems together with opioid analgesia. Depth of sedation was assessed with a modified Ramsay score and the target blood propofol setting was adjusted to achieve the sedation desired for each patient. A desired level of sedation was achieved for 84% of the sedation period. In postcardiac surgery patients the median time-weighted average propofol target setting was 1.34 microg.ml(-1) (10th - 90th percentiles: 0.79-1.93 microg.ml(-1)). Values in brain injured and general ICU patients were 0.98 (10th - 90th percentiles: 0.60-2.55) microg.ml(-1) and 0.42 (10th - 90th percentiles: 0.16-1.19) microg.ml(-1), respectively. Measured propofol concentrations were generally close to values predicted by the Diprifusor system. Target settings in the range of 0.2-2.0 microg.ml(-1) are proposed for propofol sedation in this setting with titration as required in individual patients.

Use of methoxamine in the resuscitation of epinephrine-resistant electromechanical dissociation.

We describe three cases of electromechanical dissociation under anaesthesia that were unresponsive to doses of intravenous epinephrine given according to current Advanced Life Support guidelines, but which responded immediately to the intravenous administration of the pure alpha agonist, methoxamine. We suggest a possible mechanism to explain this finding and review the literature on vasopressor drugs used for cardiopulmonary resuscitation during electromechanical dissociation. An intravenous alpha agonist, such as methoxamine 20 mg, should be considered for any case of cardiac arrest secondary to electromechanical dissociation which is unresponsive to epinephrine given according to current guidelines.

Use of cognitive state predicates by language-impaired children.

Two studies of the use of cognitive state predicates by children with specific language impairment (SLI) were conducted. Study I analysed longitudinal language samples collected from 26 children with SLI and 25 children with normal language (NL) development, aged 4;4 and 2;11, respectively, at Time I. Study II analysed samples from SLI children with more severe delays at an earlier language stage. There were 10 SLI children and 10 NL children, aged 4;11 and 2;8, respectively, matched by MLU. All cognitive state predicates were identified using both broad and narrow definitions. In Study 1, the SLI children used cognitive state predicates less frequently than their mental age peers, and with no greater frequency or variety than their younger, language peers. In Study II, children with SLI used more predicates referring to communication events, but there were no further group differences. These findings are discussed as they relate to two current psycholinguistic issues: the possible dissociation of grammar and the lexicon, and the role of language in the development of children's theory of mind.

An alternate MLU calculation: magnitude and variability of effects.

This study investigated the effect of removing elliptical question responses, imitative utterances, and single-word Yes/No responses before calculating MLU. Forty-seven language samples from preschoolers with and without language impairment were analyzed. Initial MLUs ranged from 2.0 to 6.5 across both groups. The alternate calculation procedures resulted in an average 18% increase in the MLU index, with individual samples increasing as little as 3% or as much as 49%. The magnitude of the effect was primarily related to discourse properties, although in the SLI group there were secondary relationships to language level and proficiency. The observed variation in the discourse properties of language samples makes the alternate MLU index attractive to clinicians and researchers.

Genotypic characterization of strains of commercial wine yeasts by tetrad analysis.

The objective of this work was to use tetrad analysis to define the genotypes of a number of commercially available wine yeasts for a range of characteristics related to wine making. The levels of sporulation and spore viability of 13 wine yeasts were determined. Sporulation was very low in one strain and varied from low to high in the other 12 strains. Spore viability of these 12 strains varied from 0-95% and this range was comparable to a large sample of naturally-occurring wine strains. Colonies from viable spores, predominantly from 4-spored asci, from 11 strains were characterized for the ten traits: homothallism/heterothallism, fermentation of sucrose, galactose, maltose; growth on glycerol (nonfermentable); slow growth on glucose and glycerol; level of sulfide production; copper resistance; putative presence of a recessive lethal mutation (inviability of at least two spores/tetrad); yellow pigment (in colonies) on sugar media. The number of heterozygosities for these ten characteristics varied from zero to seven in 11 strains, and eight strains were genetically distinct. Another three strains, distinct from these eight strains, were identical for the ten characteristics and also equivalent for the levels of sporulation and spore viability. Although these three strains are marketed under different designations, there is a strong probability that they were derived from a common ancestral strain. The genotypic characterization of these 11 strains constitutes an important foundation for their identification and their use in breeding programs.

Meningococcal septicaemia: treatment with protein C concentrate.

Meningococcal septicaemia is a devastating disease with the potential to develop severe vascular complications. The incidence in Northern Ireland has risen from 27 cases notified in 1992 to 56 notified in 1997. We describe the first use of protein C concentrate in addition to antithrombin III infusion in the management of a life-threatening case of meningococcal septicaemia in the Regional Intensive Care Unit, Royal Group of Hospitals, Belfast, UK. The rationale and the evidence to support the use of protein C concentrate are discussed. Despite the apparent efficacy and safety of this treatment, subsequent cases of meningococcal septicaemia have not received protein C concentrate due to a lack of availability.

Developing profiles of risk for parental abduction of children from a comparison of families victimized by abduction with families litigating custody.

This study systematically compared parents in abducting families with families litigating custody. Findings indicate that risks for parental abduction of children are multidetermined by: (1) a heightened concern about very young children being exposed to neglectful, endangering, or criminal environments by the other parent; (2) unsubstantiated allegations of sexual abuse; (3) heightened distrust of and less respect for law and authority; and (4) a reluctance to seek help from the courts. Abducting families were also predominantly socially and economically disadvantaged: parents were less likely to have been married to one another; they had lower incomes, were more poorly educated, and were disproportionately members of minority racial and ethnic groups. The social policy dilemmas of identifying these differences as risk factors are discussed together with suggestions for risk management.

Tolerance of large exchange volumes by peritoneal dialysis patients.

Improving clearances on peritoneal dialysis involves either more exchanges, greater fill volume, or both. An increase in the number of exchanges is inconvenient, resulting in noncompliance. Therefore, the best option is to increase the exchange volumes; however, patients are often reluctant for fear of discomfort. We tested the tolerance of 20 patients blinded to randomly sequenced volumes of 2, 2.5, and 3 L, performed incenter by the dialysis nurse. Each patient underwent one to three exchanges with each volume. At the end of a 4-hour dwell, the patient scored discomfort and estimated the infused volume. Only one study exchange was performed each day; the rest of the time, the patient continued his or her usual prescription. Fifteen of the patients (75%) were not able to identify the exchange volumes. Four of the five patients who determined the correct exchange volume for 67% to 78% of the exchanges (P < 0.04 compared with 33% expected by chance) had a body surface area greater than 1.75 m2. Of 123 exchanges, 84% were associated with no discomfort, 10% with mild discomfort, and 6% with moderate discomfort. Patients were not more likely to have discomfort with 3-L compared with lower fill volumes. Peritoneal clearances of creatinine (6.1 v 6.6 v 7.7 mL/min/1.73 m2) and urea nitrogen (7.3 v 8.6 v 9.5 mL/min) were progressively greater with increasing exchange volumes (P < 0.001). We conclude that the majority of small as well as large patients will tolerate 2.5- and 3-L exchange volumes. If encouraged to do so, many patients could tolerate greater exchange volumes than they are presently using. Exchange volumes should be readily increased as residual renal function declines.

Hospitalization in peritoneal dialysis patients.

Hospitalization rates are declining more rapidly for peritoneal dialysis (PD) than for hemodialysis patients. This has been postulated to be caused in part by lower peritonitis rates. However, the causes of admission have not been reexamined in the setting of declining rates. We prospectively examined our hospitalization rates, causes of admission, and impact of peritonitis on hospitalization in adult PD patients at a single center over a 4-year period. There were 274 admissions in 168 patient-years for a rate of 1.6 admissions and 13.0 hospital days per patient-year. Rates were greater for men (1.8 v 1.5; P = 0.013), patients with diabetes (2.2 v 1.4, P < 0.001), and those with a higher peritoneal equilibration test result. Creatinine clearance and sex were independent predictors in a multivariate analysis. The most common causes for admission were cardiac disease (14.6%) and peritonitis (13.5%). Peritonitis accounted for 0.21 admissions and 2.0 hospital days per patient-year. Thirty percent of the incident patients were admitted during the first 90 days of dialysis. Admissions for dehydration and glucose abnormalities were more common in the first 90 days. Overall admission rates, as well as admission rates for peritonitis, did not change over time, although hospital days per year decreased. Those admitted for peritonitis had higher peritonitis rates, more time on PD, and were more likely to be black. Eighty-one percent of the admissions for peritonitis were caused by Staphylococcus aureus, Streptococcus spp, or gram-negative/fungal peritonitis. Patients with peritonitis caused by Staphylococcus epidermidis were less likely to be admitted than patients with peritonitis caused by other organisms. To conclude, peritonitis remains a common cause of hospitalization, despite low peritonitis rates. To decrease admissions for peritonitis, attention should be focused on preventing peritonitis caused by organisms other than S epidermidis.

Vitamin K deficiency with hemorrhage after kidney and combined kidney-pancreas transplantation.

Vitamin K deficiency is a common occurrence in the surgical and intensive care unit population, but its incidence in kidney and combined kidney-pancreas allograft recipients has not been described. We report four patients who received cadaveric kidney or combined kidney-pancreas allografts and subsequently developed significant bleeding associated with deficiency of vitamin K. Their coagulopathy promptly resolved with the parenteral administration of vitamin K. Treatment with vitamin K should be considered in kidney or combined kidney-pancreas allograft recipients with a prolonged prothrombin or partial thromboplastin time during the first postoperative week to avoid hemorrhagic complications.

Diabetic nephropathy with concurrent hepatitis C virus infection related membranoproliferative glomerulonephritis.

Diabetes mellitus is often complicated by nephropathy with progression to renal failure. Various forms of glomerulonephritis have been associated with diabetes, sometimes resulting in more rapid deterioration in renal function and occasionally dictating alternative management of these patients in attempts to reverse or contain nephrosis or renal failure. We report the occurrence of Type I membranoproliferative glomerulonephritis (MPGN) with hepatitis C virus (HCV) infection in two patients, in association with diabetic nephropathy. One patient had cryoglobulinemia and cryoglobulin deposits in the kidney. A brief review of the literature on glomerulonephritides occurring in patients with diabetes mellitus is also presented. Clinicians should be aware of the possible occurrence of Type I MPGN and cryoglobulinemia in patients with diabetes mellitus and HCV infection with the appropriate history and physical findings. The therapeutic approach to managing patients with two distinct concurrent lesions remains unresolved.

A prospective, randomized trial to compare tacrolimus and prednisone with and without mycophenolate mofetil in patients undergoing renal transplantation: first report.

PURPOSE: Between September 20, 1995 and September 20, 1996, 120 patients were entered into a prospective, randomized trial comparing tacrolimus and prednisone with (61) and without (59) 2 gm. mycophenolate mofetil daily to determine whether mycophenolate mofetil was associated with a lower incidence of rejection. MATERIALS AND METHODS: Mean recipient age plus or minus standard deviation was 50.8+/-14.1 years (range 18.8 to 84.1). Mean donor age was 34.3+/-21.7 years (range 0.01 to 76). Of the donors 18 (15%) were older than 60 years. Mean cold ischemia time was 30.9+/-8.4 hours (range 14.2 to 49). Median followup was 8.6+/-0.5 months. RESULTS: The 6-month actuarial patient survival was 95%, 92% in the double therapy group and 98% in the triple therapy group (not significant). The 6-month actuarial graft survival was 88%, 84% in the double therapy group and 92% in the triple therapy group (not significant). The overall incidence of rejection and steroid resistant rejection was 34.2 and 4.2%, respectively. There was a strong trend toward less rejection in the mycophenolate mofetil group than in the double therapy group (26.2 versus 42.4%). Crossover was common, and was 42.6% from triple to double therapy and 18.6% from double to triple therapy. The reasons for discontinuation of mycophenolate mofetil were gastrointestinal toxicity, primarily diarrhea, or less commonly hematological toxicity, primarily neutropenia or thrombocytopenia. Gastrointestinal toxicity was ameliorated by separating the doses of tacrolimus and mycophenolate mofetil by 2 to 4 hours, and reducing the dose to 1 gm. daily. CONCLUSIONS: Mycophenolate mofetil appears to be a useful third agent with tacrolimus in patients undergoing renal transplantation, and is associated with a reduction in the rate of rejection and a low incidence of steroid resistant rejection. There is a high incidence of gastrointestinal toxicity associated with the 2 gm. daily dose but this complication is relatively straightforward to manage.

Duodenal obstruction in polycystic kidney disease. Case report and review of the literature.

Polycystic kidney disease in a common inherited disorder accounting for 8-10% of cases of end-stage renal disease. The enlarged kidneys often produce pain and hematuria but rarely obstruction of surrounding organs. We report a case of autosomal dominant polycystic kidney disease producing symptomatic duodenal obstruction and malnutrition. Duodenal obstruction should be considered in the differential diagnosis of a patient with polycystic kidney disease and intermittent or persistent nausea and vomiting.

T-wave amplitude: relationships to phasic RSA and heart period changes.

T-Wave Amplitude (TWA) has been suggested as an indicator of sympathetic influence on myocardial performance, but critics have argued that TWA is confounded by parasympathetic influence or that it is a non-specific feature of tachycardia. To help clarify the issue, we examined TWA as a function of parasympathetic activity, using cardiac vagal control as measured by high frequency components of heart period variability (respiratory sinus arrhythmia) and of interbeat intervals (IBI), across several stressful tasks. Sixteen male subjects were exposed to Valsalva, Serial Subtraction and Cold-Pressor tasks. After controlling for between-person variance, it was found that RSA did not contribute to TWA and that IBI contributed dependably to TWA only during the Valsalva maneuver, when heart rate was driven very high. In light of these results, we recommend that TWA continue to be considered a candidate indicator of sympathetic influence on myocardial performance, although caution should be used if heart rate is dramatically elevated.

Propofol and alfentanil total intravenous anaesthesia: a comparison of techniques for major thoracic surgery.

BACKGROUND: Previous work has highlighted the disadvantages of propofol as a sole agent for total intravenous anaesthesia (TIVA). This randomised study investigated three combinations of propofol and alfentanil as TIVA for major thoracic surgery. METHODS: In 73 patients undergoing elective thoracic surgery, anaesthesia was conducted either with sodium thiopentone induction and inhalational maintenance (incorporating isoflurane) or with TIVA using propofol with alfentanil (by infusion at one of two rates or in incremental doses). Vital signs and recovery characteristics were recorded. RESULTS: There were no significant differences in heart rate or blood pressure between groups during either induction or maintenance. Depth of anaesthesia was controlled satisfactorily in all groups. Recovery characteristics were similar between treatment groups, although there was a trend towards earlier orientation in the group which received the highest infusion rate of alfentanil. CONCLUSION: Continuous infusions of propofol and alfentanil provide safe and reliable TIVA for major thoracic surgery. TIVA was found to be a satisfactory technique in more elderly patients than previously described. The higher of the two alfentanil infusion rates may result in a better combination of propofol and alfentanil with respect to recovery times than the lower.

Children of Armageddon. Common developmental threats in high-conflict divorcing families.

This article traces how parental vulnerability to the feelings of humiliation and loss (inherent in highly conflicted divorce and custody litigation) distorts parenting capacities and parent-child relationships in distinctive ways, putting children at risk for specific kinds of developmental difficulties. Pre-oedipal children often fail to achieve a complete separation from their primary caretakers. Oedipal children, already struggling with separation issues, manifest sexualized anxiety and discomfort with gender identity. By latency, these children present as fragmented within themselves and in relationships with others. Each stage-specific response is discussed and illustrated. It is argued that mental health and legal professionals can use this in-depth understanding of child responses to help parents reframe their disputing agendas in terms of the child's developmental concerns and preoccupations to produce custody settlements that are more protective of the child's best interests.

Cognition and communication: referential strategies used by preschoolers with specific language impairment.

Ten children with specific language impairment and 10 children with normal language development were asked to describe objects so that a listener could select them. Each trial targeted two out of a group of three toys. The targeted objects were identical or were similar in size or color. Children in the two groups did not differ in referential success, although children in both groups found the size items more difficult. Content analysis of the messages did reveal differences in the referential strategies used most frequently. Children with specific language impairment were more likely to mention the attributes of each object separately, rather than to describe the characteristics common to a pair of objects. Children in both groups talked about separate objects more often when talking about size than about color or object type. Use of this strategy could indicate the effects of attentional capacity on children's solutions to communication tasks.

Acute renal failure in recipients of organ transplantation and nontransplantation patients: comparison of characteristics and mortality.

Mortality from acute renal failure in critically ill patients remains in excess of 50% despite decades of improvement in supportive care. It is not known whether replacement of other failing organs by non-renal organ transplantation affects mortality in acute renal failure. We retrospectively reviewed the course of 169 patients with acute renal failure managed at a single university medical center over a 1-year period. Measures of disease severity (need for renal replacement therapy, mechanical ventilation or parenteral nutrition, presence of oliguria and APACHE II scores) and final outcome were compared in 97 patients with acute renal failure who did not receive transplants and 72 patients with acute renal failure who underwent non-renal solid organ transplants. Overall mortality was 50.3% and directly correlated with APACHE II score. Compared to nontransplant patients, transplant recipients were younger. more frequently male, and less often oliguric; but the groups were similar in mean APACHE II scores and need for renal replacement therapy, prolonged mechanical ventilation, and parenteral nutrition. Overall, mortality was significantly lower for transplant patients compared to nontransplant patients (34.7% vs. 61.9%, p < 0.05). In nonoliguric acute renal failure and renal failure not requiring renal replacement therapy, mortality was low and similar in both transplant and nontransplant patients. Compared to nontrasplant patients with similar risk factors and similar APACHE II scores, mortality was significantly lower for transplant patients who were oliguric, or who required renal replacement therapy, mechanical ventilation, or parenteral nutrition. Organ transplantation is associated with a survival advantage in acute renal failure when compared to the outcome of critically ill nontransplant patients. The relation between APACHE II scores and survival is altered by transplantation.